CHIR12007

Clinical Assessment and Diagnosis

Portfolio Exercises Week 9 & 10

Exercise 1

Differential Chart

Please create a chart that lists as many differential diagnoses for hip pain as you can, including but
not limited to the following conditions

Osteoarthritis (most common)

• Degeneration of the articular cartilage with subsequent narrowing of the joint space and
osteophytes
• Osteoarthritis of the hip joint may be a source of hip and groin pain.
– Normal load on abnormal joint
– Abnormal load on normal joint
• >50yo but can occur earlier if the hip has been affected by another condition
• More common in males (knee > in females)
• Unilateral is common, can have bilateral
• Hip = Superior Joint + axial jt + medial jt

Physical finding:
– Insidious onset of anterior hip, thigh and groin pain with stiffness
– Pain may radiate to the gluts
– Symptoms worse in the morning (~30 min-1 hour), activity-related pain
– With advanced changes, may develop nocturnal pain and discomfort lying on the
affected hip.
– Gait may be antalgic and an abductor limp may be present.
– Range of motion is decreased by pain, particularly internal rotation & Ext rot.
– Deep, achy joint pain exacerbated by extensive use
– Reduced range of motion and crepitus often
– Stiffness during rest
– Morning joint stiffness usually lasting for less than 30 mins
– Shortening of limb
– Reduced internal rotation is a classic feature
Specific Testing:
• Flexion Adduction Test
• Faber Patrick
• Cluster of Sutlive
• Scour (osteophytes, compress head of femur),
• Heel strike test (fracture, OA)

Investigations
o Radiographs demonstrate loss of joint space, osteophytes and other degenerative
changes.
o MRI – gold standard
Treatment:
• Assess lifestyle factors, explain nature of overuse of joint, weight loss
• correct postural problems
• Cl lie down in the prone 30min/day to prevent development of Hip flexion deformity
 • Non weight baring activities: pool exercises, focus on flex, int/ext rot, ext.
• Soft tissue releases, TP, PNF stretches, Mobilization, long axis distraction, stretches,
adjustments
• Walking stick in opposite hand allows weight redistribution onto the normal hip and ease
pain in affected hip.
• Analgesics may be required for pain.
• isometric exercises for weakness/ wasting in thigh and gluteal muscles. To overcome
stiffness, they may be combined with assisted exercises, e.g. with the use of a sling to
stretch the hip in extension
• glucosamine

1. When pain is dominant, mobilisation of the hip joint should at first use small-amplitude
movements without provoking any further pain. As pain settles, treatment is progressed
by using rotational movements and the amplitude of these movements is gradually
progressed until a full rocking from medial to lateral rotation can be done.
2. When pain and stiffness are major problems, the hip is first treated in flexion and
adduction and accessory movements are used at the end of the range.
3. Glucosamine and other supplements may be useful.
DDX:
 FAI
 AVN
 DDH (developmental dysplasia of the hip)
 Labral tears
FemoroAcetabular Impingement (FAI)
• Motion related disorder of the hip
• Characterized by early abnormal contact between skeletal prominences of the
acetabulum and femur that limit the physiologic ROM of the hip, particularly flexion and
internal rotation
• Two general types of femoroacetabular impingement (FAI) have been described.
• Cam type
• Most often seen in young athletic men
• Caused by a deformity on the femoral side.
• The femoral deformity is an aspherical femoral head due to a bump
(impingement exostosis, cam lesion) at the junction of the femoral head
and neck, impinges on the acetabular rim.
• This impingement leads to abrasions or avulsion of the involved
acetabular cartilage, which may lead to tearing of the non-involved
labrum.
• Pincer type
• More common in middle-aged athletic women.
• Caused by deformity on the acetabular side
• Focal or generalized over-coverage (deep socket/ acetabulum) that
creates an obstacle for flexion and internal rotation.
•
• 86% have a combination of both = Mixed pincer and cam
Physical finding:
– Recurrent episodes of sharp hip and groin pain
– Pain may be out of proportion to radiographic findings
– Pain on weight bearing and with hip flexion such as walking uphill, sitting or
jumping*
– Pain increases with loadbearing such as running, squatting

Specific Testing:
– Positive impingement provocation test
• Pain on flexion plus internal rotation

Investigations
– X-ray
• CAM
• Pincer
– Diagnosis of acetabular retroversion may be made by observing a
‘crossover’ sign on x-ray films; the posterior and anterior walls of
the acetabulum cross each other.

Management:
– If unrecognized, can lead to early, severe osteoarthritis and may require hip
replacement
– Activity modification
• Non-weight bearing (short term)
• Muscle strengthening to relieve stress
• Non-loadbearing activities (swimming)
– Accelerates cartilage healing
– NSAIDs
– Surgery may be required
• Arthroscopic labral tear debridement
• Femoral reshaping
• Periacetabular osteotomy
• Hip replacement

Osteitis Pubis
• Inflammation of the pubic symphysis and surrounding muscle insertions
• Causes
• Overuse injuries (athletes)
• Postsurgical instability
• Must be excluded as a cause of groin pain, particularly if there are bilateral groin and
lower abdominal symptoms
Physical finding:
• Insidious onset
• Focal tenderness at the pubic symphysis
• Made worse by exercise, straining or adopting certain postures (such as standing on one
leg)
• May be felt while walking upstairs or thrusting the hip forward.
• Pain may be severe, so that running or kicking is virtually impossible
• May cause the patient to limp.
• +/- clicking sensation on certain movements.
• Pain and tenderness also occur over the tendons of the adductor longus and the rectus
abdominis near their attachments on the pubis
• Pain reproduced by passively abducting the hip, by resisting the patient’s attempt to sit up
or by resisting adduction of the hip.

Investigations:
• Lab values (to eliminate causes such as infection
– CBC ( Complete blood count), ESR (Erythrocyte sedimentation rate), UA
(Urinalysis)
• X-ray
• MRI or CT

Bursitis’
– Iliopsoas
• Anterior hip pain, greater with activity which progresses to pain at rest
• Tender to palpation in the femoral triangle
– Greater trochanteric
• Pain over the greater trochanter
• Worse with activities such as standing, walking, stair-climbing or running
• May be worse at night when lying unaffected hip
• Risk factors
– Repetitive overuse
– Hip injury
– Spine disease (Scoliosis, Lumbar spine OA)
– Leg length inequality
– Previous surgery around the hip

Specific Testing:
• Sign of the buttock
Snapping Hip
• Refers to conditions about the hip that cause an audible or palpable ‘snapping.’
• This condition is commonly seen in dancers, gymnasts and runners.
• The cause can be intra-articular or extra-articular.
– The most common cause involves snapping of the iliotibial band or the tensor
fascia lata over the greater trochanter (external snapping).
– Less commonly, the iliopsoas tendon may snap as it slides over the iliopectineal
eminence or the iliofemoral ligament may slide over the femoral head (internal
snapping).
• The patient may describe an associated pain, crepitation and local warmth, but activity is
rarely impaired.
• Physical examination focuses on localising the source of the click and associated
discomfort.
 • Treatment consists of correcting muscle imbalance and tightness of the involved
structures with PIR, and correcting biomechanical misalignments using orthotics.

Strains
• Most common symptom is muscle pain
• Grading
– Grade 1 (primary)
• Minimal disruption of the musculotendinous junction
• Weaknesses generally absent
– Grade 2 (secondary)
• Partial tear with intact musculotendinous fibres
• Weakness associated with separation of muscle from tendon or fascia
– Grade 3
• Complete rupture of musculotendinous junction
• Loss of function with complete myofascial separation
• Grade 3b
– Avulsion fracture at tendinous origin or insertion
• Hamstring is most frequent side of involvement
• Generally young athletes
– Sprinters, football/soccer, basketball, rugby

• Treatment of acute injuries begins with rest from aggravating activities for 1 to 2 weeks.
Myofascial release, electrical stimulation, icing, compression and NSAIDs provide
symptomatic relief.
• Exercise therapy should begin as soon as pain allows and should initially include isometric
contractions without resistance, followed by isometric contractions against resistance, the
limit being pain.
• After the initial phase of inflammation has subsided, patients can begin a stretching
programme. Heat increases the extensibility of the collagen in tendons and muscles and
is useful for the remainder of the treatment program. Preventive training and correction
of predisposing factors (e.g. intrinsic muscle tightness, muscle strength imbalances, or
muscle weakness) should be included in a complete rehabilitation program.
• If a patient does not respond to conservative treatment of a groin pull within two weeks,
osteitis pubis should be suspected.

Groin (ADDuctor) Strain

• Most commonly injured adductor of the hip
• Pain feels like a sudden stab in the groin
• There may be swelling and bruising localized to the origin of the adductor longus
• Caused by forced external rotation of the abducted hip
• Pain with resisted adduction and passive stretch in abduction
• DDX other causes of anterior hip pain; radiculopathy from L/S (usually associated back
pain)

Rectus Femoris Strain

• Pain from a rectus femoris strain may be felt from the area anterior to the acetabulum
and may radiate to the thigh and inguinal area.
• May have inability to extend knee
• Pain can be reproduced by resisted hip flexion or resisted knee extension.
• The risk of myositis ossificans is increased in cases of significant muscle bleeding.
• Wrapping the affected area with ice and an elastic bandage, with the knee in maximum
 flexion, is optimal therapy in the first 24 hours. NSAIDs should be avoided in the first 48
hours.
• DDX other causes of anterior hip pain; radiculopathy from L/S (usually associated back
pain)

Iliopsoas Strain:
• Strain of this strong hip flexor commonly occurs in weight lifting, uphill running and sit-
ups.
• Tenderness associated with this strain is difficult to palpate, since the iliopsoas muscle
inserts on the lesser trochanter of the femur.
• Pain can be elicited by having the patient flex the hip 90 degrees and then try to flex it
further against resistance or by passive stretching with hyperextension at the hip.
• Conservative treatment as outlined for the muscle strains
• The TrP immediately below the inguinal ligament, in the tendon of the iliopsoas where it
is in close relationship to the femoral artery, just before it inserts into the lesser
trochanter can be a cause of groin pain. Deactivation of the TrP is best carried out with
the thigh abducted and externally rotated
Rectus Abdominus Strain:
• The chief lower abdominal wall injuries in active patients include rectus abdominis strain,
inguinal hernia, ilioinguinal neuralgia and sports hernia. Strain of the rectus abdominis is
usually caused by overloading, as in weightlifting or doing sit-ups. Pain is localised at the
origin and is reproduced by elevating the legs and/or the head with the patient supine. A
rectus abdominis strain can be difficult to differentiate from an intra-abdominal process
such as appendicitis. A key diagnostic clue is localised tenderness that is accentuated
when the patient contracts the muscle and decreases with muscle relaxation.
• Three conditions associated with chronic overload of the adductor muscles are
1. Osteitis pubis
2. Pubic stress fracture
3. Adductor avulsion fracture/ syndrome

Hamstring Strain
• Common cause of hip or posterior thigh pain
• Biceps femoris is the most frequently injured of the hamstring muscles
• Caused by hip hyperflexion + knee extension
• Chronic repetitive trauma
• Running
• Risk factors include
• Insufficient pre-activity stretching
• Muscle imbalance
• For flexibility
• Previous hamstring injury
• Clinical
• Gluteal pain and tenderness
• Pain when sitting
• Pain and tightness with forward kicking and hamstring stretches
• Injury can occur at the ischial tuberosity or proximal tendon
• Conservative treatment as outlined for the muscle strains

Specific Testing:

Inguinal Hernia:
 • Hernias are common enough that every patient with groin pain should be examined to
eliminate this possibility.
• An inguinal hernia is located above and medial to the pubic tubercle.
• A femoral hernia, more common in female patients, occurs below and lateral to the pubic
tubercle.
• Inguinal hernias result from weakness or tear of the posterior wall of the inguinal canal
(transversus abdominis).
• In most cases, activities that increase intra-abdominal pressure or involve repeated
Valsalva’s manoeuvres, such as weightlifting, cause or exacerbate hernia.
• Manoeuvres to increase intra-abdominal pressure, such as coughing or tensing the
abdominal musculature, may produce a cough impulse or make the mass more
prominent.
• The pain will often radiate into the proximal thigh or scrotum in males.
• Examination for both types of hernia involves invagination of the scrotal skin along the
spermatic cord using the index finger in males or direct palpation in females.
• Inguinal hernias should be surgically repaired.

Neuropathies
• Ilioinguinal
• Obturator
• Genitofemoral
Specific Testing:
Radiculopathies
• Referral of pain to the skin overlying the inguinal area can be due to mechanical disorders
of the T12-L1 area. Pain on palpation and mobilisation of the spinous processes of the
lower thoracic and upper lumbar spine may point the examiner to the correct origin.
• Nerve root compression from L2 to L4 may mimic hip disease by causing referred pain in
the inguinal area and the anterior aspect of the thigh. In these cases, neurologic deficits
and a positive femoral nerve stretch test in the absence of pain or limitation of motion of
the hip should evoke the diagnosis.

Physical finding:
Specific Testing:
Avascular Necrosis
Avascular necrosis (AVN), also called osteonecrosis or bone infarction, is death of bone tissue due
to interruption of the blood supply. Early on, there may be no symptoms. Gradually joint pain may
develop which may limit the ability to move. Complications may include collapse of the bone or
nearby joint surface.
Risk factors include bone fractures, joint dislocations, alcoholism, and the use of high-dose
steroids. The condition may also occur without any clear reason.
Infection
History:
Physical finding:
Specific Testing:

Tendinopathies
History:
Physical finding:
Specific Testing:
Piriformis Syndrome
History:
 Physical finding:
Specific Testing:
Lumbar disc disease
History:
Physical finding:
Specific Testing:

(where possible, note those factors that help to differentiate the condition – historical, physical
finding, specific testing or any other factor that may be helpful

Child Perthes
Slipped Epiphysis
Developmental Hip Dysplasia
Infection Hip pain nothing makes it
better, fever, generally unwell,
rapid progressive
Synoitis Hip pain nothing makes it
better, low grade fever,
generally unwell, cranky rapid
progressive

DDX by location:

 Anterior:

• Hip joint disease

• Hernia

• Disk pathology (L2 innervation of lower discs)

• Iliohypogastric (L1) neuropathy

• Ilioinguinal (L1) neuropathy

• Genitofemoral (L1-2) neuropathy

• Femoral nerve (L2-4) neuropathy

• Lumbar plexopathy (L1-4)

• Iliopsoas tendinitis/bursitis

• Calcific tendinitis of iliopsoas tendon

• Capsular/ligamentous distention in hypermobility syndromes

 • Bone insufficiency fracture of pubic rami

Lateral:

• Trochanteric bursitis/tendinitis

• Iliotibial band tightness

• Lumbar spine pain radiation

• Maigne’s syndrome (T12)

• Iliohypogastric (L1) neuropathy

• Meralgia paraesthetica (L2-3)

• Leg length discrepancy

• Sarcoma

• Metastatic cancer

• Incomplete fracture of femoral neck

• Osteomyelitis

• Asceptic necrosis

• Myofascial pain syndrome

Posterior:

• Lumbar spine and SIJ pain radiation

• Hip disease

• Ischial bursitis

• Ischial bone lesions

• Calcific tendinitis in the posterior proximal thigh

• Sarcoma

• Myofascial pain syndrome

Exercise 2

Osteonecrosis will be presented in lecture in week 10 however, this can occur in locations other than
the hip.

Please create a table/ chart that lists the locations where Osteonecrosis can occur.

Osteonecrosis can develop in any bone, most often in the:

 Thigh bone (femoral head).

 Upper arm bone (humerus).
 Knees (medial femral condyle)
 Talus (dome)
 Lunate
 Bone marrow cavity (intermedullary infarct) – deep sea diving, sickle cell anaemia

Exercise 3

There are 4 major conditions that can affect the paediatric hip and may present with hip pain. Please
list these, noting the main clinical features and identify those features which may help to
differentiate these.

Hip Conditions Main Clinical Features

Legg-Calve’-Perthes Disease:  Insidious onset
 Perthes' disease (3-12 years  Vague groin pain that may extend down to the
peaking at 5-7 years). knee with a limp
 May cause a painless limp
 A true idiopathic  A child with knee pain should have the hip
osteonecrosis of the proximal examined! 
femoral epiphysis in children  Examination
 Seen most often in males o Decreased internal rotation and
between 4 to 8 abduction
 Most cases are unilateral, o Gait disturbance
12% are bilateral  Antalgic limp
o Asymmetric and  Trendelenburg gain
asynchronous  Limb length discrepancy (LLD) is a
 Is thought that obliteration late findings
of the lateral arterial group  Positive orthopedic tests
of arteries that supply the  Patrick-Fabere
femoral head causes the  Trendelenberg 
necrosis
o Abnormal clotting
factors
o Repeat subclinical
trauma and
mechanical overload
o ? Maternal/ passive
smoking aggravates
 Associated
conditions
o ADHD in 33%
o Delayed bone age in
89%
 Stages of the disease

Transient synovitis (irritable hip)
peaking at 3-8 years.
 pain in the hip, thigh, groin or knee on the
affected side. There may be a limp (or abnormal
crawling in infants) with or without pain. In small
infants, the presenting complaint can be
unexplained crying (for example, when changing a
diaper).

Septic arthritis - any age (peaking  Patients will most commonly present with a single
swollen joint causing severe pain. Pyrexia will be
 at 0-6 years). in around 60% of affected individuals (although its
absence should not rule out septic arthritis).

 On examination, the joint will appear red,

swollen, and warm, causing pain on active and
passive movements. An effusion may also be
evident.

 Often the joint is rigid and the patient will not

tolerate any passive movement at all, and will be
unable to weight bear. Symptoms are more florid
and obvious in native joint injection; in prosthetic
joint infections, the features can be more subtle.

SCFE (early adolescence - usually  Slipped capital femoral epiphysis (SCFE) is a hip

in obese children). condition that occurs in teens and pre-teens who
are still growing. For reasons that are not well
understood, the ball at the head of
the femur (thighbone) slips off the neck of the
bone in a backwards direction.

Exercise 4

Self directed learning:

Please research ‘Myositis ossificans’ and present the history, clinical findings and importance of this
condition. Note: this does not solely apply to the hip!

Myositis ossificans is an unusual condition that causes bone to form deep within muscles of the
body.  Often this condition is found in young athletes who sustain a traumatic injury, or sometimes
as a result of repetitive injury to the muscle.  Most commonly found in the thigh, and sometimes in
the forearm, myositis ossificans often occurs in athletes such as football or soccer players.

S/S:

 Aching pain within the muscle that persists longer than expected for a normal muscle
contusion
 Limited mobility of joints surrounding the injured muscle
 Swelling of the muscle group, and sometimes extending throughout the extremity

The common concern when abnormal bone is seen on an x-ray is that there could be a tumor within
the soft-tissues.